Background/Purpose: The American College of Rheumatology strongly recommends using a treat-to-target (T2T) strategy because it has demonstrated improved outcomes compared to a non-targeted approach in RA. The crux of a T2T based strategy is accurate disease activity measurement using a composite disease activity tool like Clinical Disease Activity Index (CDAI) and then adapt therapy as necessary until the clinical target is met. The aim of our study is to measure concordance between usual care-treatment decisions and CDAI-based T2T treatment decisions and to identify reasons for discordance, if any. This is a crucial step in our internal validation of CDAI and development of a T2T-based treatment pathway.

Methods: Adult RA patients in our tertiary care rheumatology clinic during the period of 5/20/16 to 5/20/17 were prospectively identified. First, as part of the usual care treatment approach currently used at our clinic, a shared treatment decision was made after consideration of all patient, disease, and treatment related factors. Then a T2T based mutual disease target was established with the patient and a CDAI was scored to determine if the patient has met target or not. The ideal T2T strategy based treatment decision was recorded for study purposes to compare with the usual care decision. We measured concordance between the T2T and usual care treatment decisions, compared characteristics of concordant and discordant groups, and of those where the Patient Global Assessment of Disease Activity (PtGA) contributed to ≥ 50% of the total CDAI score. We recorded patient, disease and treatment related data at each visit.

Results: Patient demographic, RA disease and treatment related data can be found in Table 1. Of the total 40 patients, 9 patients were in remission and were excluded from the analysis as there was low likelihood of discordance. Of the remaining 31 patients, there were 9 instances (29%) of discordance between T2T and usual care treatment decisions. There were higher number of patients with ≥ 1 musculoskeletal comorbidity (osteoarthritis, bursitis, etc) -67% in the discordant group vs 32% in concordant group. There were slightly higher numbers of patients with ≥ college education in the concordant group (63%) than in the discordant group (50%). PtGA contributed to ≥ 50% of total CDAI score in 21 patients of the cohort (68%), and of these 43% had ≥ 1 musculoskeletal comorbidity.

Conclusion: In our small group of 40 RA patients, we found 29% discordance between the T2T and usual care treatment decisions, and the PtGA contributed to ≥ 50% of the total CDAI score in 68% patients. As accurate disease activity measurement is central in any T2T strategy, we believe that this deeper understanding of variation in CDAI, PtGA scores and T2T decisions is very useful. We have accordingly started using PtGA as a patient education opportunity and plan to repeat this study with a new amended CDAI questionnaire.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/do-rheumatoid-arthritis-clinical-disease-activity-index-based-treat-to-target-treatment-decisions-always-correspond-to-usual-care-treatment-decisions-at-point-of-care/